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Merchant Application Form

Please complete the questionnaire below to your best ability and we will be in touch within 24 hours to discuss the next steps.

merchants-apply-01

- Step 1 of 7

First, please provide your contact information. We'll use these details to get in contact with you if we have any questions.

Name *

First

Last

Email *

Email

Confirm Email

Phone *

International format including country code and area code. For example, for USA and Canada, please enter +1 888 888 8888.

Please provide some details about the company.

If you are unsure on any detail, please feel free to skip any non-required field. We can follow up with you to discuss after the application is processed.

Company Name *

Company Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Company Identification Number

May be the Incorporation Number, VAT ID, EIN, ABN, etc.

Company Industry

The main industry that the company operates in.

Company Description

Please provide a brief description about your company, boardly what products are sold, how long you have been operating, number of staff members, and target markets.

Additional Contact Form *

Not Required
Add Additional Contacts

If you would like to provide additional contact information for key personnel on your staff, such as Technical, Accounting, or Support, please indicate in the above. You'll be able to change this after the application and once your account is set up.

Technical Contact Name

First

Last

Technical Contact Email

Email

Confirm Email

Account Contact Name

First

Last

Account Contact Email

Email

Confirm Email

Support Contact Name

First

Last

Support Contact Email

Email

Confirm Email

Your company's processing details and history

Sales Website / URL *

The main website where your product/services are sold.

Current Approval Rate

Percentage (or ratio) of transactions which are approved. Example: 80% or 0.80.

Average Ticket Amount

Average amount per order (or ticket) in dollars.

Average Monthly Volume

Total volume of approved payments processed per month, on average. Example: $40,000.

Accepted Payment Types

Visa
Mastercard
American Express
Discover
JCB
Paypal
Other

Other Payment Types Accepted

If 'Other' was selected above, let us know what other payment types you accept.

Ratio of Accepted Payment Types

Example: 55% Visa, 25% Mastercard, 20% AMEX

Acquirer and Payment Service Provider Information

Payment Service Provider *

Who currently provides your payment facility: might be Shopify Payments, Stripe, Direct Bank MID (e.g. Chase Bank).

Payment Gateway

Are you using a Payment Gateway such as NMI, Authorize.Net.

Location

Location of your Payment Processor, Terminal or MID.

Acqurier BIN

Merchant ID (MID) or Card Acceptor ID (CAID)

PayShield Service Selection

Please let us know what PayShield products and services you are interested in.

PayShield Services *

Chargeback Alerts (Verifi and Ethoca)
Express Resolve Chargeback Alerts API and Service
Chargeback Protection Guarantee
Transaction Recognition (TxFind)
Customer Communications (TxComms)
3D Secure
Fraud Scoring

Are you currently using any of the above services from another company? *

Yes
No

Current Service Providers

If you are receiving the above services from a company already and looking to move to PayShield, please let us know the company and the service.

This is everything we need for now. Please click the submit button below to submit the application.

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